We take your symptoms and an evaluation of your entire endocrine system to determine how to treat you, as an individual. Please take the time to fill out the following forms and questionnaires before your visit. and bring them completed along with your insurance card. The questionnaires, although lengthy, help us identify the cause of your problems so that we can get you feeling better quicker. 6811 N. Knoxville Ave., Ste. A Peoria, IL 61614 309.439.9400 2309 E. Empire St., Ste. 200 Bloomington, IL 61704 309.740.7970 www.lifeplusmd.com
WOMEN S INTAKE FORM www.lifeplusmd.com Name: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email: SSN#: Date of Birth: / / Age: Height: Weight: Occupation: Marital Status: Primary Insurance Information Employer: Company: Primary Address: Primary ID Number: Primary Group ID: Primary Cardholder Information Name: Address: City: State: Zip: SSN#: Date of Birth: / / Age: Secondary Insurance Information Secondary Address: Secondary ID Number: Secondary Group ID: ASSIGNMENT AND RELEASE I, the undersigned verify that. to the best of my knowledge. the information above is correct. I assign directly to (Inspirit Health PC / LifePlus MD) all insurance benefits. If any. otherwise payable services are rendered. I understand that I am financially responsible for changes whether or not paid by insurance. By signing this form I fully understand that (Inspirit Health PC / LifePlus MD) Is not a participant of Medicaid or Medicare and will not provide services to Medicaid or Medicare patients at this time. I hereby authorize release of information necessary to secure the payment of benefits. I authorize the use of this signature in all insurance submissions. Signature Relationship Date
MESSAGE AUTHORIZATION www.lifeplusmd.com Patient Name: Date of Birth: / / Please Circle Yes or No for the following questions: Do you give the staff at LifePlus MD permission to leave messages on your voice mail? YES NO If Yes, please specify phone number(s) we we can leave voice mail: Do you give the staff at LifePlus MD permission to send appointment reminders via text and email? YES NO Do you give the staff at LifePlus MD permission to discuss your healthcare needs with your spouse or other designated person? YES NO If yes, please list spouse/designated individuals and phone contacts: Signature Date
Primary Care and Specialty Doctors: Doctor s Name: Location: Doctor s Name: Location: Doctor s Name: Location: Allergies: Pleae list all allergies to medications (if any) and what reactions have occurred (if any): Medications: Pleae list all prescription medications you currently take, including samples. Medication Name Dose Number of times per day Doctor 1. 2. 3. 4. 5. 6. 7. Herbal/Supplements: Pleae list all vitamins, herbs, enzymes, protein supplements, pro-hormones or any other supplements. 1. 2. 3. 4. 5. 6. 7. Past Medical History and Current Medical Conditions: Pleae check all that apply to you. Heart Disease Diabetes Cancer Epilepsy Hormone Related Issues Bladder Infections Blood Clots Diagnosed Obesity Lung Disease High Blood Pressure Depression Thyroid Disease Headaches Fatigue Abnormal PAP High Cholesterol Arthritis Ulcers Head Trauma Kidney Stones lnsomnia Prader-Willi Syndrome
List any other medical conditions that you currently receive treatment for (medical, chiropractor, physical therapist, etc.). Surgical History: Family History: Pleae list any illness that any of the following members of your family have had. Mother: Deceased q Yes Father: Deceased q Yes Siblings: Deceased q Yes Siblings: Deceased q Yes Children: Deceased q Yes Children: Deceased q Yes Gynecological History: Age of first period: Age of last period: Date of last PAP: Doctor/Location: Have you ever had an abnormal PAP? q Yes If yes, please elaborate? Are you sexually active? q Yes Are you trying to get pregnant? q Yes Please list any birth control methods. Are your periods regular? q Yes How many days do your periods last? Any abnormality with flow? q Yes Any cramps? q Yes Any premenstrual symptoms? q Yes Any fluctuations in timing of periods? q Yes Starting and ending when? Any bleeding between periods? q Yes Any pelvic pressure or fullness? q Yes When was your last period? Any unusual vaginal discharge or itching or recurrent urinary tract infections? q Yes Please describe: Number of pregnancies: Number of children:
Lifestyle Information: Do you use? If Yes, how often and how much? Tobacco (Chew, Smoke, Snuff) q Yes Alcohol q Yes Caffeine (Soda, Tea, Coffee) q Yes Artificial Sweeteners q Yes Do you snore or stop breathing when sleeping? q Yes Insomnia q Yes Sleep Apnea q Yes Diet: Do you have an eating plan that you follow? q Yes If Yes, please describe Exercise: Do you exercise regularly? q Yes If Yes, how often and how much? Stress Management: Do you practice any stress management techniques? q Yes If Yes, how often and how much? Body Image: Are you comfortable with your current weight and size? q Yes Do you struggle to lose weight? q Yes General Health: Do you think your health is good? q Yes If No, please explain Goals: What do you hope to accomplish at LifePlus MD? 1. 2. 3. 4.
Symptoms Report: Pleae indicate if the following symptions apply to you. www.lifeplusmd.com Headaches q Yes Decreased Libido q Yes Anxiety/Panic Attacks q Yes Breast Swelling q Yes Breast Tenderness q Yes Moodiness q Yes Foggy or Fuzzy Thoughts q Yes Sleep Disturbances q Yes Vaginal Dryness q Yes Dry Hair/Skin q Yes Depression q Yes Hair Loss q Yes Heart Palpitations q Yes Flushing or Hot Flashes q Yes Frequent Yeast Infections q Yes Painful Intercourse q Yes Irritability q Yes Weight Gain q Yes Concentration Problems q Yes Shortness of breath q Yes Night Sweats q Yes Inability to have orgasms q Yes Fluid Retention q Yes Breast Lumps or Fibroids q Yes Loss of sex drive q Yes Bleeding Abnormalities q Yes Heat or Cold Intolerance q Yes Excessive Sweating q Yes Nervousness q Yes Burned Out/Past Peak q Yes
Adrenal Function and Evaluation: Pleae indicate if the following statements apply to you. I have low blood pressure.... q Yes I get dizzy or see spots when standing up rapidly from a sitting or lying position.... q Yes I feel as though I might faint or black out.... q Yes I have acute of chronic fatigue (lack of energy).... q Yes I have low energy before lunch or dinner.... q Yes I usually feel better after 6pm.... q Yes I often feel the best late at night because I get a second wind.... q Yes I have trouble getting asleep.... q Yes I tend to wake early (approx. 3am - 5am) and have trouble getting back to sleep.... q Yes I need to rest after times of mental, physical, or emotional stress.... q Yes I feel more tired after excercise or physical exertion, either soon after or the next day.... q Yes I have chronic tenderness in my back near the bottom of my rib cage.... q Yes I have a back pain / joint pain / chronic inflammation.... q Yes I am allergic to many things, such as food, animals, and pollens.... q Yes My allergies are getting worse.... q Yes I become hungry, confused, or shaky if I miss a meal.... q Yes I crave sugar, sweets, or desserts.... q Yes I use stimulants, such as tea or coffee, to get started in the morning.... q Yes I need caffeine (chocolate, tea, coffee, sodas) to get me through the day.... q Yes I often crave salt and/or foods high in salt, such as potato chips.... q Yes I do not eat regular meals.... q Yes I have taken steroid medications for a long term or at high doses.... q Yes I have symptoms that improve after I eat.... q Yes I get more than 2 colds or flus per year.... q Yes I do not exercise regularly.... q Yes I am emotionally stressed.... q Yes I tend to be a perfectionist.... q Yes I tend to avoid stressful situations for the sake of my health.... q Yes I am less productive at work than I used to be.... q Yes My ability to focus mentally is generally impaired.... q Yes Stress causes me to become overly anxious.... q Yes My sex drive is very low or non-existent.... q Yes My relationships at work and/or home tend to be strained.... q Yes My life contains insufficient time for fun and enjoyable activities.... q Yes I have little control over my life and I feel stuck.... q Yes I tend to get addicted easily to drugs, alcohol, or food.... q Yes
Adult Growth Hormone Deficiency Assessment: Pleae indicate if the following statements apply to you. I struggle to finish jobs.... q Yes I feel a strong need to sleep during the day.... q Yes I often feel lonely even when I am with other people.... q Yes I have to read things several times before they sink in.... q Yes It is difficult for me to make friends and/or hard for me to mix with people.... q Yes It takes a lot of effort for me to do simple tasks.... q Yes I have difficulty controlling my emotions.... q Yes I often lose track of what I want to say, or forget what people say to me.... q Yes I lack confidence.... q Yes I have to push myself to do things.... q Yes I often feel very tense.... q Yes I feel as if I let people down.... q Yes I feel worn out even when I m not doing anything.... q Yes There are times I feel very low.... q Yes I avoid responsibility if possible.... q Yes I avoid mixing with people I don t know well.... q Yes I feel as if I am a burden to people.... q Yes I find it difficult to plan ahead.... q Yes I have to force myself to do things that need doing.... q Yes My memory lets me down.... q Yes Thyroid Function and Evaluation Tool: Pleae indicate if the following statements apply to you. Do you feel exhausted from morning to night?... q Yes Do you have trouble getting up in the morning?... q Yes Do you have morning stiffness?... q Yes Do you have trouble working under pressure?... q Yes Do you have trouble losing weight no matter what you do?... q Yes Are you constipated?... q Yes Do your muscles feel weak as if they can t generate energy?... q Yes Is your cholesterol over 200?... q Yes Do you have or did you have PMS or menstrual difficulty?... q Yes Have you ever had trouble with fertility?... q Yes Do you have low body temperature?... q Yes Do you use any sort of thyroid supplementation?... q Yes Do you have a history of anemia or bruise easily?... q Yes